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Affidavit Citizenship Form Mo by tow41088

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									                                             CITY OF O’FALLON
                              PUBLICLY FUNDED PROJECTS AFFIDAVIT
                                                 Building Safety Department
                                         100 North Main Street, O’Fallon, MO 63366
                                                636-379-5599 / 636-240-2000


This form is to be filled out whenever a commercial permit is applied for after January 30, 2006
when the project is funded with public money per Ordinance Number 4949.

DATE:                                      Project Funded with Public Money?         Yes        No

Project Name:

Project Address:

Contractor Name:

Contractor Address:



Contractor Phone No.


1.   I, the contractor, and my subcontractors have worker’s compensation insurance to cover all
     our employees working on the above named project.  Yes          No

2.   I, the contractor, and my subcontractors have verified the U.S. citizenship or lawful status of
     all workers employed on the above named project.  Yes             No

3.   I, the contractor, and my subcontractors will pay the prevailing wages of the area to my
     workers.  Yes           No

4.   I, the contractor, and my subcontractors are in compliance with federal law requiring an
     accredited apprenticeship program if such law applies to the project.  Yes         No

5.   I, the contractor, understand that upon request of the City, I will produce proof of compliance
     with the above laws within 72 hours.  Yes            No


If this project is funded with public money, I understand by answering “No” to any of the above
statements would be a violation of Ordinance Number 4949.

I hereby certify the above to be true and accurate in all respects to the best of my knowledge and
belief.

Signature:                                                              Date:

								
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